Lipoprotein (a) in young individuals as a marker of the presence of ischemic heart disease and the severity of coronary lesions.

The purpose of this study was to evaluate whether high levels and small isoforms of lipoprotein (a) [Lp(a)] are markers of risk of early myocardial infarction and markers of the severity of coronary atherosclerosis. Lp(a) levels and small apo(a) isoforms were higher in 222 patients than in 199 controls (p<0.001). In patients, Lp(a)> or =30 mg/dL was associated with the presence of coronary lesions (p=0.007) and the severity of coronary atherosclerosis (p=0.002). The present study suggests that Lp(a) levels and small isoforms are markers of early myocardial infarction and that Lp(a) levels > or =30 mg/dL are associated with severe patterns of coronary atherosclerosis.

The presence of epsilon waves in a patient with acute right ventricular infarction.

Epsilon wave is an unusual electrocardiographical finding, which may appear in other pathological conditions besides the arrhythmogenic right ventricular dysplasia, particularly in the acute myocardial infarction of the right ventricle, the inferior, or the posterior wall of the left ventricle. Its real incidence in these acute coronary syndromes remains unknown and will be probably difficult to assert, since it may be unnoticed by inexperienced physicians because of its little voltage. The outstanding interest of this case lies in the clear electrocardiographical images and in the step-by-step differential diagnosis discussed by the authors.

Predictive value of brain natriuretic peptide in the diagnosis of heart transplant rejection.

AIM: To evaluate the pattern of brain natriuretic peptide (BNP) concentration in heart transplant (HT) recipients and its relation to the degree of graft rejection determined by endomyocardial biopsy specimen. METHODS: We studied 71 consecutive HT recipients (62 men, 53 +/- 11 years). The patients underwent 383 biopsies. Creatinine and BNP concentrations and hemodynamic parameters were determined along with the degree of graft rejection using endomyocardial biopsy specimens. We considered treatable rejection as International Society for Heart and Lung Transplantation Grade >or=2 in the first 90 days and >or=3A thereafter. We included a control group of 36 healthy individuals. RESULTS: Brain natriuretic peptide concentration was significantly greater among HT recipients (264 +/- 318 pg/ml) than in controls (17 +/- 16 pg/ml). In the first 90 days, BNP concentration was significantly greater among the patients with graft rejection (510 +/- 470, n = 84, vs 278 +/- 255, n = 87; p < 0.0001), although the corresponding discriminatory capacity was small. After the first 90 days, BNP values were similar in patients with and without graft rejection (170 +/- 297, n = 17, vs 142 +/- 203, n = 195; p = not significant). Creatinine concentration increased with time after transplantation and did not correlate with BNP concentration. We observed significant positive correlation between BNP concentration and hemodynamic parameters. CONCLUSIONS: Brain natriuretic peptide concentration remains increased after HT, with stabilization after the 4th month. Brain natriuretic peptide concentrations are slightly greater among patients with treatable rejection, particularly in the first 90 days, although BNP concentration lacks discriminatory capacity to serve as a guide to performing biopsy.

[Analysis of factors that can influence the appearance of acute heart transplant failure]. / Análisis de los factores que pueden influir en la aparición del fallo agudo del corazón trasplantado.

INTRODUCTION AND OBJECTIVE: Acute graft failure (AGF) is defined as significant failure of myocardial function in a newly implanted heart. The aim of the present study was to investigate a series of factors related to heart transplantation (HT) in relation to AGF. MATERIAL AND METHOD: In a study of 287 consecutive HTs performed over a 14-year period, AGF was defined when: a) the surgeon observed ventricular dysfunction before closing the sternotomy; b) various inotropic drugs were required at high doses in the first days after surgery, or c) ventricular dysfunction was identified by routine echocardiography in the immediate postoperative period. Statistical analysis comprised a descriptive and univariate comparative study, followed by multivariate analysis based on application of a logistical regression model. RESULTS: The incidence of AGF was 22%. Predictors of AGF were female donor status (OR = 2.2; 95% CI, 1.2-4.4; p = 0.02), a disproportion of more than 20% in donor-recipient body weight (OR = 2.2; 95% CI, 1.1-4.3; p = 0.02), and background ischemic heart disease (OR = 2.5; 95% CI, 5.5-1.1; p = 0.03) or valve pathology (OR = 5.0; 95% CI, 7.0-1.5; p = 0.01). CONCLUSIONS: AGF is a frequent pathology, which was present in 22% of our heart transplantation patients. Among the modifiable factors related to AGF was a clear disproportion in body weight and the size of grafts from female donors. Unmodifiable factors related to AGF were ischemic heart disease and valvular heart disease as a cause of heart transplantation.

[Usefulness of the electrocardiogram in predicting the occlusion site in acute anterior myocardial infarction with isolated disease of the left anterior descending coronary artery]. / Utilidad del electrocardiograma para predecir el lugar de la oclusión en el infarto agudo de miocardio anterior con enfermedad aislada de la arteria descendente anterior.

INTRODUCTION AND OBJECTIVES: In acute anterior myocardial infarction (AMI), the site of occlusion in the left anterior descending coronary artery (LAD) is related to the extension of myocardial necrosis and the prognosis. The aim of this study was to assess the value of the electrocardiogram (ECG) as a predictor of the LAD occlusion site in patients with anterior AMI. METHODS: Forty-five consecutive patients with a first anterior AMI and isolated disease of the LAD were included. We evaluated retrospectively the ECG with the most pronounced ST-segment changes before fibrinolysis and correlated the findings with the site of LAD occlusion in angiography before hospital discharge in relation to the first dominant septal and first diagonal branch: first septal affected (S), first diagonal affected (D), both affected (S + D), or neither affected were considered. RESULTS: ST depression in leads II, III, or aVF strongly predicted proximal LAD occlusion in S + D, S, and D (p = 0,003, p = 0,04, and p = 0,02, respectively). ST elevation in leads II, III, or aVF was observed only in the presence of wrap-around LAD and was related with occlusion distal to the first diagonal branch. ST elevation > or = 3 mm in lead V1 was a specific predictor of occlusion proximal to first septal (S, p = 0,01). ST elevation in aVR was associated with proximal LAD occlusion in S + D and S (p = 0,03 and p = 0,03, respectively) and absence of coronary collateral circulation. CONCLUSIONS: In anterior AMI and isolated LAD disease, the ECG can be useful in predicting the LAD occlusion site in relation to its major side branches.

[Brain natriuretic peptide. Diagnostic value in heart failure]. / Péptido cerebral natriurético. Valor diagnóstico en la insuficiencia cardíaca.

BACKGROUND: Nowadays a number of diverse biochemical markers have been identified in patients with heart failure (HF) that could indicate the severity of the patients' illness. Among them, probably the most useful is brain natriuretic peptide (BNP) because it is easily obtained and because of its diagnostic and prognostic information. Our objective was to assess the association between BNP and other different associated variables previously known to be related to the evolution of HF, as well as its utility to distinguish systolic from diastolic HF. PATIENTS AND METHOD: We studied 114 patients admitted consecutively for symptomatic HF for all causes (age: 66 years, male: 60%). In all patients plasma BNP was measured, from the third day of admission, with a specific radioinmunoassay. Echocardiography was performed in 101 patients. RESULTS: BNP plasma levels increased in proportion to functional class (p = 0.01) and the degree of left ventricular dysfunction (p = 0.0001, r = 0.44). There was also an association between BNP and male sex (p = 0.008), higher plasmatic creatinine (p = 0.01, r = 0.25), Iarger ventricular diameters (p = 0.0001) and higher pulmonary systolic pressure (p = 0.001, r = 0.44). In the multivariate analysis, BNP was independently related to the rest of variables with left systolic ventricular function (p = 0.0001). Despite this association, we did not find a satisfactory cut-off value in BNP, with a good sensitivity and specificity value from the total number of patients, of which specifically systolic dysfunction as a cause of HF was detected. CONCLUSIONS: a) BNP increases proportionately to the left ventricular dysfunction and HF severity, and b) BNP is not a useful tool to distinguish systolic from diastolic HF.